Author: Anthony Sanfilippo
It’s science, not speculation, that will get us through this.
Why do COVID patients experience such profound hypoxia without feeling dyspneic?
Why is there such heterogeneity in clinical severity among young, previously healthy patients?
Are asymptomatic people able to carry and transmit the virus, and for how long?
Does immunity develop after infection, and how long does it persist?
Does antibody status indicate complete protection from re-infection?
Do currently available anti-viral agents have effect?
Will previous approaches to vaccine development be effective?
These are some of key questions still under investigation as we now pass 6 months since this infection originally came to attention. The answers to these questions are the keys to resolving the greatest heath and economic catastrophe the world has faced. The answers will not be provided by scientists or politicians working in isolation, but rather by the application of scientific approaches, supported by political and economic action.
This past week, we’ve seen examples of how this can work well, and how a lack of synergy will impede progress.
In Canada, our government has announced a billion dollar investment in COVID-19 medical research, and support for a Task Force to determine the extent of the disease.
- Trudeau announces $1.1-billion for COVID-19 research (https://www.theglobeandmail.com/politics/article-trudeau-announces-11-billion-for-covid-19-research/)
- Government of Canada funds 49 additional COVID-19 research projects (https://www.canada.ca/en/institutes-health-research/news/2020/03/government-of-canada-funds-49-additional-covid-19-research-projects.html)
- Ottawa to fund existing coronavirus research projects (https://www.theglobeandmail.com/politics/article-ottawa-to-fund-existing-coronavirus-research-projects/)
In Germany, a nation-wide public health investigation has begun to carry out widespread serologic testing intended to define the true extent of disease and implications of prior infection.
- With Broad, Random Tests for Antibodies, Germany Seeks Path Out of Lockdown (https://www.nytimes.com/2020/04/18/world/europe/with-broad-random-tests-for-antibodies-germany-seeks-path-out-of-lockdown.html?ref=oembed)
- Blood tests show 14% of people are now immune to covid-19 in one town in Germany (https://www.technologyreview.com/2020/04/09/999015/blood-tests-show-15-of-people-are-now-immune-to-covid-19-in-one-town-in-germany/)
In the United Kingdom, vaccine development is well underway with massive investments already in place.
- UK boost support for CEPI to spur COVID-19 vaccine development (https://cepi.net/news_cepi/uk-boosts-support-for-cepi-to-spur-covid-19-vaccine-development/)
All these have come about through effective collaborations between government, funding agencies and scientific and medical communities. We’ve also seen examples of what can transpire when those collaborations are not effective. We’ve seen that, even if well intentioned, speculative assertions by a political leader can be assumed by the public to be scientifically informed and thereby lead to dangerous actions.
- U.S. President and top doctor spar over unproven drug (https://www.theglobeandmail.com/world/article-trump-vs-fauci-us-president-and-top-doctor-spar-over-unproven-drug/)
- Nigerians poisoned after taking doses of drug praised by Trump (https://www.theglobeandmail.com/world/article-at-least-two-cases-of-chloroquine-poisoning-in-nigeria-after-trump/)
- Trump’s COVID-19 disinfectant ideas horrify health experts (https://www.reuters.com/article/health-coronavirus-trump-disinfectant-idUSKCN2261OL)
- Lysol maker warns against internal use of disinfectants after Trump comments (https://www.nbcnews.com/politics/donald-trump/lysol-manufacturer-warns-against-internal-use-after-trump-comments-n1191586)
There has been much debate in recent years within the medical education community regarding the relevance of research and critical appraisal in undergraduate medical education. These topics have been gradually and rather insidiously receiving decreased attention in favour of the many other competencies and “hot items” that have been emerging, all with justification. I would suggest that recent events have resolved that debate. The questions posed at the beginning of this article were not posed exclusively by basic scientists and epidemiologists, but also by clinicians trained to accurately observe patient responses, critically assess current understanding and pose valid, useful hypotheses for testing. Clinicians will also be very much involved in developing protocols and executing investigations to find answers. Medical schools have a responsibility to ensure that fundamental training continues to be a core component of their programs, now more than ever.
Getting students back into the clinical workplace. Why? When? How?
Medical education is not just a program for building knowledge and skills in its recipients… it is also an experience which creates attitudes and expectations.
It’s long been appreciated that medical education must provide much more than academic knowledge about human biology and pathology. It must also provide opportunities to observe and participate in the application of that knowledge to real people with real problems. In fact, the earliest forms consisted entirely of “on the job’ practical experience in apprenticeship-like arrangements with practicing physicians. The contemporary model of medical education incorporates the Clinical Clerkship which, since early in the twentieth century, has provided opportunities for medical students to work alongside fully qualified physicians and make active contributions to clinical care while observing, learning and advancing their skills. It has been modified considerably over the years, extending into a variety of clinical settings and incorporating embedded formal learning activities. It has proven highly effective in preparing students to both develop fundamental skills and better understand their own place in the rapidly expanding world of clinical medicine.
Until, that is, about a month ago.
As a result of the massive disruptions caused by the COVID pandemic and as reported in the last edition of this blog (https://meds.queensu.ca/ugme-blog/archives/4797), it became unavoidably necessary to pull medical students from their clinical placements. This was not because of a lack of perceived value, but because the simple logistics of maintaining safe and educationally viable experiences in the face of the stresses currently being faced by our hospitals and faculty became insurmountable. Since then, students have been undertaking an on-line, remotely delivered curriculum intended to provide learning that would normally have been undertaken in conjunction with their clinical placements. By doing so, it’s hoped they will be in a better position to complete their training within whatever time remains when clinical placements are eventually resumed.
Over the past few weeks, medical schools across the country have been almost continuously engaged in discussions to determine when and under what circumstances students will be able to re-engage this very necessary component of their education.
Why the rush?
Firstly, these clinical placements are essential components of learning and training. To undertake medical education without experiencing clinical application would be like trying to learn to play the piano without ever touching one. One might learn everything about how the instrument is constructed, how it works and the principles of music, but could never become a musician without guided, progressive application of all that knowledge.
Secondly, Clinical Clerks are able to provide useful clinical service. Although their scope of activity is obviously limited, they are able to off-load certain tasks to allow more advanced learners and fully qualified physicians more time to concentrate on more complex patient interactions and procedures, all the time observing and learning through active participation. They will also, and very importantly, learn the value and satisfaction that comes from helping provide useful service to patients and thus further their growth as professionals.
Thirdly, and very pragmatically, failure to graduate on time will be very damaging. Our medical schools serve our society and are expected to provide a steady infusion of trained physicians to the Canadian workforce. There will be a point at which insufficient time is available to complete degree requirements. A failure to graduate the 2021 class on time, or close to it, will result in gaps in that supply line, at a time when need is particularly urgent and is likely to continue well into the future. In addition, overlapping with subsequent classes will put further stresses on already limited clinical training sites and have implications well into the future.
Finally, it must be recognized that the students of today will be the leaders and front-line providers of whatever health care crises face our society in the future. We must not deny them the learning that this crisis provides. There is valuable, perhaps unique, learning available to them that will shape not only their understanding, but their attitudes and personal preparedness.
For all these reasons, much thought has been given to the “when”. In doing so, a number of principles and practical criteria have been developed.
Principle 1: Patient Safety.
Would the presence of students in the clinical environment jeopardize or promote optimal patient care?
- Would students be able to provide valuable service by “off-loading” specific aspects of care from other providers?
- Would students increase the risk of disease transmission?
- Would students consume valuable PPE?
Principle 2: Student Safety.
Can students be protected from, or excluded from, excessive risk?
- Although some small risk is inherent in any clinical placement, would students be exposed to risks considered above the “norm”, or without protections and considerations that would be reasonably expected?
- Will students be provided with the full, minimum PPE that is suggested as required by scientific knowledge with respect to COVID-19?
- Are there local occupational health processes in place to protect students who may be exposed to COVID-19?
- If it is deemed essential to exclude students from some clinical situations and not others, can that exclusion be reliably achieved?
- Do current student liability arrangements cover the current clinical environment?
Principle 3: Safety of clinical teaching faculty and hospital staff.
Would student placements jeopardize the safety or wellness of teaching faculty or other hospital staff?
- Would students provide valuable service that would be of benefit to faculty or other providers?
- Would students integrate into care teams as currently constituted during this crisis?
Principle 4: Learning.
Can a valuable learning experience be provided?
- Are there sufficient roles in which students can engage?
- Do these roles have educational value?
- To what extent is any involvement at this time a valuable and possibly unique learning experience?
Principle 5: Supervision.
Are there sufficient clinical teaching faculty available to provide student supervision?
- Can continuing oversight of learners be provided?
- Can learners be assessed?
- Are these available in all areas necessary to provide a full clerkship experience?
In terms of the “how”, criteria such as these will be continuously assessed and the current state of readiness for re-entry evaluated on an ongoing basis. It’s understood that a certain minimum time, at least a month, will be required to “on-board” students to the altered workplace. The earliest possible return is therefore always at least a month displaced from a final decision. At this point, only the most optimistic estimates would suggest a return before July.
In addition, schools are striving very hard to coordinate their efforts and synchronize both entry and graduation dates. Given the differences in curricula and clerkship structures across the country, and the differing regional impacts of COVID, it seems unlikely all schools will reach a state of preparedness at precisely the same time, but there is strong commitment to minimize discrepancies.
There is also a growing recognition that the elements of clerkship and the residency matching process are almost certainly going to be substantially altered. Discussions about the number and type of elective opportunities that will be available, and the implications for residency selection are very much “on the radar” of undergraduate programs, postgraduate programs and CaRMS, but substantive decisions must await more clarity about timing of return and graduation dates. Whatever those dates, schools all recognize the critical importance of ensuring that all graduates are provided equivalent opportunities to achieve graduation requirements and engage residency positions.
It will be important through this process to maintain full transparency and communication between schools and, critically, with our students whose lives and careers are literally “on hold”. This article is an attempt to promote that communication, which will no doubt continue across our country in the weeks and months ahead.
Stay tuned. We will get through this, together.
The Crisis is the Curriculum. Education in the Midst of COVID-19
When I was a young father fretting about whether I was doing all I could to advise and guide my children, a very wise man provided some sage advice. “If there’s one thing I know about young kids, it’s that they don’t listen to much of what you say, but they watch everything you do.” His point was that we teach through example. Our behaviour, the decisions we make and the principles that we rely upon to guide those decisions are what really matter. They are what impress and persist in the memory of learners.
That advice has withstood the test of time and, I’ve found, extended beyond parenthood to influence my perspectives on medical education. As factual information becomes more widely and easily accessible, medical students have less and less need for didactic teaching, but more and more need to understand how to manage that information and, importantly, how to “live the life” of a practicing physician. How decisions are made. How uncertainty is engaged. How stress and fatigue are managed. They’re watching, and they’re very astute observers.
All this has never been truer than during the current COVID-19 crisis.
The roles and routines of our students have been altered dramatically. In a short period of time, the first and second years have shifted from a curriculum featuring predominantly whole-class presentations, small group learning and regular clinical skills sessions with standardized and volunteer patients, to a remotely delivered curriculum that they’re accessing individually from their homes scattered across the country. Clinical Skills is being “parked”, to be made up when circumstances allow, in a manner not yet determined.
Our final year students have, fortunately, completed their clinical rotations and are also utilizing remote access to complete their curricular requirements. They are on schedule to graduate and enter their residencies July 1, but are facing adjustment and disappointment, with the cancellation of Convocation ceremonies, delay of the MCC Part 1 examination to some future date, no doubt after they start residency, and the uncertainty of what sort of hospital environment they will be engaging.
Perhaps the greatest impact has been on our third year class. About three weeks ago, we had to make the very difficult decision to suspend their clinical placements. This was not because of a lack of perceived value, but because the simple logistics of maintaining safe and educationally viable experiences in the face of the stresses currently being faced by our hospitals and faculty became insurmountable. For them, we are developing a completely original on-line, remotely delivered curriculum intended to provide learning that would normally have been undertaken in conjunction with their clinical placements. By doing so, we hope to be in a better position to complete their training within whatever time remains when clinical placements are eventually resumed.
How has all this been possible? Two simple answers: people and technology.
Our curricular leadership has taken on this unprecedented challenge with great creativity and tenacious dedication. Our newly appointed Assistant Dean Curriculum, Dr. Michelle Gibson, as well as Year Directors Drs. Lindsey Patterson, Andrea Guerin, Heather Murray, Susan Moffatt and Andrea Winthrop have all stepped up despite their own individual obligations at this time to develop and manage this transformation. Assistant Deans Hugh MacDonald (Admissions), Renee Fitzpatrick (Student Affairs) and Cherie Jones (Academic Affairs and Accreditation) have all overseen adjustments in their respective portfolios.
Our administrative staff has managed all this with dedication, a cooperative spirit and good humour. Although working remotely in compliance with university directives, they have managed to maintain excellent working relationships and communication.
All this has largely been made possible through technologic advancements that have been under steady development for the past few years. Zoom technology, in particular, is what makes remote educational delivery possible. Our faculty has engaged this with remarkable alacrity, even the technology-challenged (myself, for example). This past week, I was able to hold a virtual Town Hall with 76 members of the fourth year class, in which I was able to both update them about key issues and hear from them on a variety of topics.
It also makes it possible for our administrative staff to “get together” for daily meetings to ensure the curriculum is being delivered effectively, and all administrative aspects of the program are attended to.
Curricular Coordinators Tara Hartman, Tara Callaghan, Jane Gordon, Vanessa Thomas, Assessment Coordinator Amanda Consack, Educational Developers Theresa Suart, Eleni Katsoulas, Student Affairs Coordinator Erin Meyer, Standardized Patient Manager Eveline Semeniuk, Admissions Team Rachel Bauder and Kristin Baker, Facility Manager Jennifer Saunders, Student Support Assistants Dana Halliday and Jessica Griscti and UG Program Manager Jacqueline Findlay are all managing their areas of responsibility with great skill at this most difficult time.
What makes the technology possible is the remarkable skill and dedication of our IT support staff, headed by Peter MacNeil.
All this is certainly impressive and worthy of recognition but, it must be recognized, it is far too early to celebrate or claim any victory. This crisis is far from over. In the weeks and months ahead, there will no doubt be new, vexing challenges that come our way. It is nonetheless appropriate to pause and recognize the efforts being made by so many, and to take comfort in the knowledge that we have the capacity and dedication to engage change.
It’s also appropriate to consider some early lessons that are emerging.
Education continues. Even if there were no formal structures or sessions in place, our students are witnessing a unique event. Their training to date allows them insights they otherwise wouldn’t have. In essence, the crisis itself is the curriculum. They are observing and learning. Much of that learning will relate to how the medical community is engaging the crisis, both collectively and individually. As I was told so many years ago, it’s not what we say but what we do that will persist.
We’re adaptable. Problems that seemed insolvable a short time ago are being solved. Impenetrable barriers are being easily breached. We’re learning to do things we didn’t have either the motivation or inclination to learn previously. And it’s working.
Communication is critical. The need to communicate efficiently and clearly has never been more apparent, or critical. Technology has allowed this to happen and, thankfully, was available when needed.
Opportunities are emerging. Circumstances are causing us to engage issues that have previously been ignored because the solutions seemed too disruptive and risky. We’re now forced to take on those issues by necessity and are beginning, in some cases, to find that those misgivings were preventing us from engaging valuable alternatives. Case in point, the role and electives in medical education will require a re-thinking and re-imagining that’s been long overdue.
And, most importantly…
Medical Students belong in the clinical workplace. All the efforts to maintain formal education remotely are certainly of great value and allow us to ensure our students are progressing in their basic learning, but it does not substitute for active engagement in the workplace. Students themselves, all across the country are coming forward to provide what service they can. They are providing home support for busy clinicians. They are manning phone lines for Public Health. They are collecting valuable equipment for use in hospitals. They’re donating blood to address current shortages. Over and above all this altruistic volunteerism, it’s becoming increasingly clear that there are many very useful roles they can play within the clinical workplace. Every medical school in the country is working tirelessly to determine when they can re-enter safely and in a supportive learning environment. Unfortunately, that doesn’t seem imminent at the time of this writing.
Finally, it must be recognized that the students of today will be the leaders and front-line providers of whatever health care crises face our society in the future. We must not deny them the learning that this crisis provides. By “watching everything we do” and through active involvement, they will emerge better prepared to engage the challenges the future.
“If I can help somebody”. Two voices challenging our concept of diversity.
You can’t be in a hurry listening to a Mahalia Jackson song. Her voice captures your attention like a moth to a flame. She extends each lyric and note, drawing you irresistibly into the heart of the song. You have to wait for her. You want to wait. You can’t not wait.
Her voice is like a warm blanket on a cold winter night. A refuge from the busy and hectic world, a place where haste is no longer a virtue and we’re reminded of the value of slow, deliberate contemplation and search for deeper meaning in what’s transpiring around us.
One of her songs, in particular, came to mind as I recently read an article about a young man named Logan Boulet. Logan was born in Lethbridge Alberta in 1997, the second child of two teachers who decided to name him for the highest mountain in Canada. He was an active child with many, constantly evolving interests. He loved hockey and more than made up for average size and natural talent with dedication, intensity and commitment to his team. His work ethic bordered on the obsessive. He eventually came to play for the Humboldt Broncos of the Saskatchewan Junior Hockey League. Logan was one of 16 people killed April 6, 2018 when their team bus was struck by a loaded tractor trailer that failed to stop at a highway intersection near Armley, Saskatchewan. His father, who was driving 15 minutes behind the bus, was one of the first on the scene.
Four weeks earlier, Logan had signed his organ donor card. He did so in honour of a former trainer who had died at 58 of a cerebral hemorrhage and been an organ donor. Logan’s heart, lungs, liver, kidney, pancreas and corneas have all been successfully transplanted.
When asked a few weeks before by his father why he decided to sign the card, Logan replied:
“If I can help save six people, I’m gonna to do it”
When I read the article, his words stuck with me. In fact, I couldn’t shake it. I’d heard those words before. Turned out it was a Mahalia Jackson song entitled “If I can Help Somebody”.
Mahalia Jackson and Logan Boulet. Hard to imagine any two human beings whose life experiences were more different. Mahalia Jackson, two generations removed from former slaves, was born in New Orleans in 1911 and lived her childhood in a three room dwelling with 12 other people, including her mother, aunts, siblings and cousins, and the family dog. She was afflicted with congenital genu varum (bowed legs) which would have caused pain and physical limitations but didn’t stop her from dancing for the white ladies for whom her mother and aunt cleaned house. Her childhood was difficult, particularly after her mother died when she was five. There was no schooling, but there was church and, with it, singing. And how she loved to sing. She was courted by choirs and choirmasters particularly after she moved to Chicago at age 20. She went on to become one of the most celebrated gospel singers of all time, the first to sing at Carnegie Hall and at John F. Kennedy’s inaugural ball. In 1963, she sang before 250,000 people assembled to hear Martin Luther King’s “I Have a Dream” speech in Washington. Five years later, she would sing at his funeral. She was an important force in the civil rights movement, but also the subject of racial prejudice and herself the target of assassination attempts. Despite all this, she remained hopeful and never embittered. When asked about her choice of gospel music over more popular forms, she said, “I sing God’s music because it makes me feel free. It gives me hope”. She is also quoted as saying that she hoped her music could “break down some of the hate and fear that divide the white and black people in this country”.
The particular song that came to mind when I read about Logan goes as follows:
If I can help somebody, as I pass
If I can cheer somebody, with a word or song
If I can show somebody, that he’s travelling wrong
Then my living shall not be in vain
Mahalia Jackson and Logan Boulet. Two very different people. Different races, genders, generations, talents, interests, culture, environment. Poster children for our concept of “diversity”. It’s hard to imagine they would ever have had occasion to encounter each other, even if they weren’t so separated by space and time. And yet, they were linked by a common value and simple, human interest in doing what they could to help people around them. Linked in their values. Linked in their humanity. And so, perhaps not so diverse after all.
Here’s a link to that song. Give it a listen, but don’t be in a hurry.
Residency Match Day: 2020 What our students are experiencing, and how to help them get through it
Anticipation is the title of a memorable Carly Simon song that tends to come to mind this time of year. That’s probably because that simple word nicely describes the prevailing mood of our fourth year class. What they’re anticipating, of course, is the results of the CaRMS match, which will be released March 3rd.
The process by which learners transition from undergraduate to postgraduate medical education has evolved into a rather jarring and extremely stressful experience (a subject for another blog/rant). It has required them to not simply consider what specialties are best suited to their interests and skills, but engage an application process that requires strategic selection of elective experiences, preparation of voluminous documents, meeting multiple deadlines (twelve, no less), and commitment of personal time and expense to travel and interviewing which, for many, spans the country in the midst of the Canadian winter. And so, as you can easily imagine, there will not only be anticipation, but also anxiety leading up to the release.
By approximately 12:00:05 on March 3rd, our students will know which program they’ll be entering next July. For most (hopefully all), the anticipation will end with the exhilaration and satisfaction of having successfully overcome the process. For a few (and hopefully none), it will bring a realization that their efforts to date have not been successful, that this part of their journey is not yet over, and they have to begin again. They will be profoundly disappointed. They will be afraid. They will be confused. They will need the understanding and help of the faculty who are currently supervising their training, and much help from our Student Affairs staff.
This year, we are again prepared to provide all necessary supports, but there are a few changes to the process which I’d like to clarify for both students and the faculty that will be supervising them that day:
- Unlike previous years, our Undergraduate Office will not automatically receive match results the day before the full release. However, students have the option of directing CaRMS to release their results the day before (March 2nd) if they fail to match. They can do so by going into the CaRMS website and providing the appropriate permission.
- Any unmatched students who have
allowed early release will be contacted directly by myself to notify them of
the result. This is for three purposes:
- to arrange for release from clinical duties
- to allow the student some time to prepare for the release moment the following day when most of their classmates will be hearing positive results
- to arrange for the student to meet our student counselors who will provide personal support and begin the process for re-application through the second iteration of the residency match.
- Unmatched students who did not opt to provide early release will similarly be contacted and offered the same support and services after we get their results on match day.
- Because we may not have full information in advance, we have decided to release all students from clinical obligations beginning noon on match day, until the following morning.
I’d also like to remind all faculty supervising our fourth year students on or around match day to anticipate that your student will be distracted. Please ensure your student is able to review the results at noon. If you sense he or she is disappointed with the result, please be advised that the student counselors and myself are standing by that day to help any student deal with the situation and provide support.
Fortunately, we have an outstanding Student Affairs team which has been working hard to guide the students through the career exploration and match process, and will be standing by to provide support for match day and beyond.
Dr. Renee Fitzpatrick
Assistant, Student Affairs
The team can be accessed through our Student Affairs office email@example.com, or 613-533-6000 x78451.
Thanks for your consideration, and please feel free to get in touch with myself or any of the Student Affairs Team if you have questions or concerns about Match Day or beyond.
I leave you, and especially our fourth year soon-to-be colleagues, with the lyrics and sounds of Carly Simon’s “Anticipation”:
We can never know about the days to come
But we think about them anyway
And I wonder if I’m really with you now
Or just chasin’ after some finer day
Is makin’ me late
Is keepin’ me waitin’
Why we teach. Why we learn.
What is it that motivates practicing doctors, nurses or any professional health care provider to take time away from their usual duties and obligations in order to teach young people whose goal is to one day replace them?
In approaching that question, a few things are clear:
It’s not because they have to. There is no obligation or requirement for active doctors or nurses to contribute to the education of student learners.
It’s not because they need ways to fill their time. There is no shortage of patients in need to fill their days with valuable work.
It’s not for the money. Educational activities are not a route to financial prosperity. In fact, time devoted to teaching is usually at the expense of time that could be spent in much more lucrative clinical work.
It’s not for the glory. Teaching requires most clinicians to move out of their “comfort zone”, engage activities for which they have little specific training or expertise, and subject themselves to criticism from learners who, it must be said, have high standards and expectations.
In fact, many days, it can be hard to find reasons. The day-to-day challenges can dominate attention and sap energy. They can lead to serious questioning and “why bother” attitudes.
And what motivates the students of medicine or nursing? Whether young or old, just entering medical school or in established practice, learning is a continuing, life-long pursuit. Although initially motivated by the need to pass examinations or receive various certifications, most of the learning that occurs through the career of a doctor or nurse is self-motivated and apparent only to themselves.
But then, once in a while, something happens to re-affirm the fundamental value of the medical education process.
Such a moment occurred last weekend in, of all places, a local supermarket. Two of our students, Alexandra Morra (Meds 2021) and Nabil Hawwa (Meds 2022) had just completed a busy day and were going about their grocery shopping when they heard a commotion in another part of the store. Approaching the scene, they came upon a number of people surrounding a man lying on the floor, unresponsive. Mr. Jim Morgan (who has provided us permission to share this story) was also shopping at that store that day. Mr. Morgan had suddenly lost consciousness and fell heavily to the floor. Alex and Nabil had never previously encountered a real-life cardiac arrest but responded instinctively. Relating the incident to me a couple of days later, they recall “zoning in” on the patient and going through their check list. Is he breathing? No. Is there a pulse. No. Start chest compressions. Call for an AED. Get somebody to call 911. Get the AED unpacked and hooked up. In doing all this, they found themselves working with a recent nursing school graduate who was visiting Kingston and was also shopping at that time. The three worked as a team, sharing a mutual understanding of the situation and common training in CPR techniques. There was no panic, no jostling for authority, no arguing. There was simply a common interest and focus on the welfare of this patient. An AED was quickly provided, deployed and a shock delivered with restoration of a rhythm just before paramedics arrived and continued the resuscitation which, we’re all delighted to report, was successful. Mr. Morgan was taken to hospital, stabilized and underwent cardiopulmonary bypass surgery two days later by Dr. Petsikas. Recovering in the CCU a couple of days later, he had opportunity to meet and thank Alex and Nabil, whose efforts and those of the (unfortunately as yet unidentified) nurse who they worked with were no doubt instrumental in his recovery.
On reflecting on all this with me a few days later, Alex and Nabil remarked on how this incident profoundly altered their perception of the learning process. Suddenly, the long hours of work and effort were no longer merely for personal or academic achievement. Learning now had a purpose. A very real, tangible purpose. It also had a face. They now want more and are re-thinking previous assumptions about career direction.
In fact, I’ve found that students will, at some point in the course of their education and training come to what I’ve come to call the “magic moment” when something happens to make them realize that they’re now able to actually, personally influence someone’s life for the better. For most, it’s something relatively modest that perhaps only they are aware of – an accurate and previously unknown diagnosis, a test ordered that led to key information, a minor procedure well executed, comfort provided to someone in distress. For Alex and Nabil, that moment was quite public and dramatic, but all are significant, provide validation and motivate further learning as can no test result or external accolade.
I learned of all this initially from Cheryl Pulling, who is a faculty member in the School of Nursing. I have had the pleasure of getting to know Cheryl over the years because of her leadership roles in education. Cheryl is Associate Director of Undergraduate Nursing Programs and so my counterpart in the School of Nursing. In addition to meeting in the context of various committees and interprofessional initiatives, Cheryl and I have an annual “date” at convocation where we have the great privilege of hooding our respective graduates. Cheryl also happens to be Mr. Morgan’s sister.
Cheryl emailed me last weekend to let me know what had happened. She was communicating because, as a fellow educator, she knew I’d be thrilled to hear of this and proud of our students. Of course, she was absolutely right about that, but she was also expressing the satisfaction we all share in knowing that our efforts are yielding results. In Cheryl’s own words:
“While they are medical students, as a faculty member I am also very proud of them. I know you would be proud if they were nursing or rehab students. We are a team in the FHS with the same goal of educating HCP for the future.”
How right she is.
And that, my friends, is why we teach.
In 2010, the World Health Organization provided the following definition of Interprofessional Education:
“Interprofessional education occurs when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”
Sounds pretty straightforward, doesn’t it? Just need a large enough room, right? In reality, developing meaningful interprofessional educational events is, to say the very least, highly challenging.
There are a number of reasons for this, some logistical and others attitudinal.
The logistic challenges are formidable. Professional schools have separate and independently developed curricular content and scheduling. Finding common ground and common space within those busy and packed programs is akin trying to get a group of busy commuters to stop and pause as they rush for the train. Moreover, any changes have to be approved by three independent Curriculum Committees, all (very understandably) aware of any impact new programming may have on their overall program. They are also very cognizant of their accreditation responsibilities which require them to ensure “centralized and independent” control of their curricula.
As difficult as these logistic challenges may be, the attitudinal barriers are even more daunting. Many students fail to see the value, being understandably focused on their individual program objectives. Many faculty members, while conceding the value, feel it is something better learned passively within the clinical environment through role modeling, and that valuable dedicated classroom time is best spent delivering what they consider more essential “core content”. These attitudes undermine the commitment that is required to overcome the logistics. In the words of Nilofer Merchant, “Culture trumps strategy, every time”. (Harvard Business Review: https://hbr.org/2011/03/culture-trumps-strategy-every)
Certainly, history is littered with partial successes or abject failures. During my tenure, I have personally been involved or witnessed numerous enthusiastic, well-intentioned and carefully thought-out approaches that have not achieved sustained success. This has been the case whether the efforts were local, or at the provincial or national levels.
Most recently, Dr. Leslie Flynn has been chairing a group that has again taken up the formidable challenge of developing a program of interprofessional education for the three schools within the Faculty of Health Sciences (Medicine, Nursing, Rehabilitation Therapy). They have developed an innovative and attractive program of learning events intended to provide both educational relevance to students of all three schools, and an opportunity for them to engage interactively. Their initial program offering begins this week.
Given the rather checkered history and recognized challenges, many might be tempted to ask, “why bother?”
A cogent rationale is provided in the preamble to the description of objectives that constitute the Collaborator competency in the CanMEDS framework:
Collaboration is essential for safe, high-quality, patient-centred care, and involves patients and their families, physicians and other colleagues in the health care professions, community partners, and health system stakeholders.
Collaboration requires relationships based in trust, respect, and shared decision-making among a variety of individuals with complementary skills in multiple settings across the continuum of care. It involves sharing knowledge, perspectives, and responsibilities, and a willingness to learn together. This requires understanding the roles of others, pursuing common goals and outcomes, and managing differences.
The College of Family Physicians takes a very similar position in its “Undergraduate Competencies from a Family Medicine Perspective” document:
As Collaborators, family physicians work with patients, families, healthcare teams, other health professionals, and communities to achieve optimal patient care.
The College of Nurses of Ontario describes the following in Entrance to Practice Competencies for Registered Nurses:
Collaborates with other health care team members to develop health care plans that promote continuity for clients as they receive conventional, social, complementary and alternative health care.
Physiotherapy Education Accreditation Canada (PEAC) is the organization responsible for accreditation of Rehabilitation Therapy programs in this country. In Essential Competency Profile for Physiotherapists in Canada, an essential Collaborator role is described as follows:
Physiotherapists work collaboratively and effectively to promote interprofessional practice and achieve optimal patient care.interprofessional practice and achieve optimal client care.
It seems then, that we all agree on the concept of Collaboration. But even more significant is the alignment about the “why bother” issue. It’s apparent from these statements that our mutual commitment is based on a shared acceptance of a fundamental truism – that collaboration provides for better patient care. Agreeing to Collaboration conceptually is not enough and, to borrow from Hamlet, “There’s the rub”. Those noble objectives ring hollow unless followed by deliberate action. That action should consist largely of what we have come to recognize as Interprofessional Education, or “IP”. IP is basically the walk that makes the talk. It actualizes our commitment to promote patient care through collaborative effort of all professionals whose training allows them to positively impact our mutual patients. It requires that we understand what others have to contribute, respect those contributions, and find ways to communicate and work together effectively.
We don’t commit to these efforts simply because they’re “the right thing to do” (although they are), or because fairness demands it (which it does), or because we wish to achieve accreditation standards (which we do). We commit to IP because, first and foremost, it’s in the interests of our patients to do so.
And that should be reason enough.
Recent lessons in the meaning of Community
What does it mean to be part of a community?
This past week, two widely reported events should cause us to consider the very nature and meaning of “community”.
The first such event, of course, is the crash of Ukraine International Airlines Flight 752 in which all 176 people on board perished, including a large number of Canadian citizens and others with close ties to Canada. Because many were involved in educational programs of various types, the Canadian university community was hard hit. The response was immediate, unified and sincere. Within my own community of undergraduate deans, there was a flurry of emails and texts expressing concern and offering support. Members of the medical student community came forward expressing concern for friends and colleagues across the country. Although some schools were more directly affected than others, all shared in the sense of loss.
Particularly revealing is that the concern and response to this disaster cut through any issues of cultural or religious background. The victims were remembered not as members of any particular group, but as people we came know as individuals, with personal traits and aspirations with which we could all identify. Obvious differences simply didn’t matter.
Later that same week, we learned of the death of Neil Peart, a member of the legendary Canadian rock band Rush and arguably one of the greatest drummers of all time. Although a member of my generation, Mr. Peart’s appeal was not confined to any age group. In fact, it was my children who drew my attention to his virtuosity and expansive lyrics. When news of his death was announced, tributes appeared on social media from diverse sources – everyone from lead singer and drummer of the Foo Fighters Dave Grohl to Prime Minister Justin Trudeau. Beyond his great talent, Peart was an iconoclast who always engaged life in his own way with an authenticity and integrity that inspired a community of admirers, young and old. From an interview with Rolling Stone in 2015, “It’s about being your own hero. I set out to never betray the values that a 16-year-old had, to never sell out, to never bow to the man. A compromise is what I can never accept.” This spirit was a rallying call that held an ageless appeal.
The very word “community” has meaning beyond its reference to a group of people living in the same location. A deeper meaning, the one that came so vividly to light in the events of this past week is “a feeling of fellowship with others, as a result of sharing common attitudes, interests, and goals.”
Tragic and sad events are an inevitable aspect of the human condition. Physicians and all health providers accept as a professional responsibility the support and assistance of individual patients and their families through such events. We are prepared and trained to do so. But when tragedy impacts the communities in which we live, we share in the loss and struggle together to find meaning.
These two recent events teach us that the concept of community transcends barriers of culture and age and helps us find some such meaning.
They remind us that community is about the forces that bind us in common interest and intent. Community provides unconditional support and strength.
Community occurs when we choose to focus on what we share rather than what separates us.
In the end, community is a choice.
Christmas wishes for our Medical Students – by the year.
Through late November and December, as darkness consumes more and more of our days, the School of Medicine Building seems to get brighter. From the outside, it seems lit for the season. Inside, the rooms and study spaces are fully occupied. It’s that time of year, of course, when first and second years are preparing for examinations. There’s also a sense of anticipation. Anticipation for the end of exams, to be sure, but also for what’s to come.
Indeed, all the world seems in anticipation as we approach the winter solstice, that moment in time when the combination of orbit and axis of the earth take us farthest from the sun and we receive the least daylight. But after December 22, the light starts to slowly return.
In the Christian tradition, this is the season of Advent, a time of expectant waiting and preparation. In the Jewish culture, Hanukkah is celebrated, known as the “Festival of Lights”, commemorating the rededication of the Second Temple. Many cultures mark the time of year in various ways, both religious and secular. For all, it’s a time that we instinctively wish to return to the familiar and comforting warmth of home. It’s a time to retreat, refresh, renew.
In the spirit of the season, I offer Christmas wishes for our students:
For first years, increasing comfort with their transition to the profession, with learning for the sake of learning, and for future patients.
For second years, deepening fascination with clinical medicine and comfort with multiple career options.
For third years, increasing confidence in the clinical environment and a growing sense of their own, individual roles within it.
For our fourth years, first choice discipline, first choice program, first time.
For all, a restful, restorative and safe break, and best wishes for the new year all it will bring.
Pivotal Court Battle Raging in British Columbia: Should preferential health care be available to those who can afford it?
A rather fierce and highly significant battle is raging in the courts of British Columbia. At stake is the future of private payer medical care in Canada. Many feel that what’s really at stake is the future of universal health care in Canada. Pragmatically, the issue boils down to whether decisions about when and how patients get care should be determined solely by need, or whether those with resources should be able to access alternative routes, and whether physicians should be allowed to provide those alternatives.
At the centre of all this is Dr. Brian Day, an orthopedic surgeon and former president of the Canadian Medical Association, who is the Medical Director and Chief Executive Officer of the Cambie Surgery Centre in Vancouver, which opened in 1996 and has been offering and providing services to insured and privately paying patients. It has been doing so despite (in the case of the privately paying patients) being in violation of the B.C. Medicare Protection Act, which prohibits physicians from working in public and private systems at the same time or, more precisely, from charging patients for publicly covered services. It also prohibits the sale of private insurance for medically necessary hospital and physician care (insurance is permitted for care not covered by the public system). It seems that for the past 20+ years the government has either made only half-hearted attempts to enforce the law, or simply “looked the other way”.
It appears that current governments are much more committed to enforce the letter of the law, and Dr. Day has mounted a challenge based on the Charter of Rights and Freedoms. He and his lawyers argue that the Charter-provided right to pursue life, liberty and personal security extends to the right to pay for care when someone feels the public system doesn’t provide it to their satisfaction. They make it clear that they are not opposed to medicare or interested in dismantling it. They point to effective blended public/private provision in many countries, claim no evidence of harm and opine that it may actually benefit the public system by “off-loading” some patients. In their closing arguments (as reported in the Globe and Mail November 13, 2019) his lawyers claim:
“Allowing British Columbians to obtain private medically necessary services would not result in any harm to either the accessibility or viability of the public health-care system, as demonstrated by the experience over the past 20 years in British Columbia, when the prohibitions on access to diagnostic and surgical services were not enforced.”
“Further, the government cannot justify imposing severe mental and physician harm on some residents on the basis of an ideological commitment to perfect equality in access to treatment, which is neither created by the legislation in question nor obtained in practice.”
There is, as one might imagine, considerable opinion to the contrary. It comes from groups such as the BC Health Coalition, Canadian Doctors for Medicare, and many individual physicians and patients who have put forward rather strongly worded counter-arguments. They feel the presence of condoned private care in BC will set precedents for the rest of Canada and undermine the principle of universal care by siphoning physicians, nurses, therapists and technicians to potentially more lucrative opportunities in the private sector. In the case of physicians, they feel this is a betrayal of the publicly financed education they’ve been provided.
The case, which has been ongoing for several months, is now in the hands of BC Supreme Court Justice John Steeves who must decide whether the BC Medicare Protection Act indeed violates Canada’s Charter of Rights and Freedom.
This impending decision, indeed this very issue, is highly significant not only for those in the medical community, but for every Canadian. Medicare has taken on a special place in Canadian cultural identity. It has become a defining element of the national character, and a source of pride of all citizens. If there are any “sacred cows” in Canadian politics, Medicare would certainly be one. But its introduction and maintenance have been far from easy.
Chief among the challenges has been the division of federal and provincial responsibility and, therefore, funding. The British North America Act of 1867 establishes among the exclusive powers of provincial legislatures,
“the Establishment, Maintenance, and Management of Hospitals, Asylums, Charities and Eleemosynary Institutions in and for the Province, other than Marine Hospitals.”
The provision of so-called comprehensive Medicare began in a piecemeal fashion in the 1940s, but gained momentum in the 1960s, largely through the efforts of the then premier of Saskatchewan, Tommy Douglas. A key step along the way was the passage in Saskatchewan in 1961 of the Saskatchewan Medical Care Insurance Act which basically guaranteed health coverage to all citizens. That included physician fees, and so Section 18 of the act includes the following:
“No physician or other person who provides an insured service to a beneficiary shall demand or accept payment for that service.”
Thus, direct physician billing to patients was essentially outlawed. Mr. Douglas turned his attention to the federal scene as he became leader of the New Democratic Party and his efforts were instrumental in the passage of the Medical Care Act of 1966, which obligated the federal government to provide half the provincial and territorial costs for medical services provided for a doctor outside hospitals. By 1972, all the provinces and territories had some form of plan to reimburse for physician services. The Canada Health Act of 1984 states in its preamble the primary objective:
“to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”
Like British Columbia, the provinces have developed legislation designed to ensure universal and funded provision of care. In Ontario the Health Care Accessibility Act of 1986 essentially outlawed billing of patients outside the provincial insurance plan, and has been subsequently reinforced by versions of the Commitment to Future of Medicare Act.
And so, what are the considerations that are likely going through Justice Steeves mind as he ponders this momentous decision?It seems obvious that government-supported medicare has the considerable advantage of ensuring a standard level of care to all patients regardless of their economic means, and of ensuring physicians are compensated.
- It seems obvious that government-supported medicare has considerable advantage of ensuring a standard level of care to all patients regardless of their economic means, and of ensuring physicians are compensated for their services.
- There seems little doubt that a decision in favour of privately funded clinics will give rise to many similar operations throughout the country, particularly in large urban centres.
- The risk of an exodus of talent from the public to private system seems real.
- There are, indeed, many examples from other countries supporting the concept that the two systems can co-exist. However, it would seem that’s only true if there is some provision for mandatory participation of physicians in the public system.
- It’s becoming apparent that the ability to fully fund “universal” care solely through the public coffer is not sustainable. We’re seeing examples of this almost daily. Hospitals, despite best efforts, are going beyond budgets to provide care, and there are clearly insufficient options for the care of needy outpatients. Not only is the population getting larger and older, but highly effective (and very costly) therapies have emerged and are continuing to emerge for the treatment of conditions that previously had no options other than palliation. Wait times are certainly lengthening, and “hallway medicine” becoming the norm.
- There’s no question that for many procedures with very long wait times, such as hip and knee surgeries, the critical bottleneck is not the availability of qualified physicians, but rather access to hospitals and operating rooms which could, theoretically, be at least partially addressed by providing privately funded facilities.
- What effect a private system would have on public system wait times is, we must honestly admit, unknown and can’t be reliably projected. It will depend, to a large extent how many private facilities emerge, what services are provided, and what constraints are put on the providers.
A critical and rather sobering consideration in all this is that the success or failure of any blended private/public model may hinge on the willingness of physicians to continue to provide care to patients regardless of ability to pay. It will test and expose their motivations and priorities. It will test their allegiance to the principles the profession has always espoused, expressed in the words of the World Health Association Oath, and taken in by most medical students, including those at Queen’s:
“I will not permit considerations of religion, nationality, race, gender, politics, socioeconomic standing, or sexual orientation to intervene between my duty and my patient”
Those who so vehemently oppose privately funded care apparently believe physicians will abandon these principles in favour of personal income. I believe, and hope, that they’re wrong. Whatever the outcome of this court case, I choose to believe that physicians will continue to use their training and skills as they were intended, for the benefit of all.
The issue of whether well-resourced citizens have a charter-assured right to more expeditious health care, and whether that privilege impinges on the rights of the less-well-resourced, seems beyond objective analysis and, in my view, is best left in the hands of a fair- minded and impartial judiciary. In the end, our system for deciding such dilemmas has been well thought out, and is worthy of our trust.
Godspeed, Justice Steeves.